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Consulting Otologist, Fordham Hospital, X. Y. C: Consult- 
ing Otologist, Manhattan State Hospital. X. \\: Con- 
sulting Laryngologist, Ossining City Hospital, Os- 
sining, X. Y.; Consulting Laryngologist, The 
Alexander Linn Hospital, Sussex, X. J.: 
Assistant Surgeon, Manhattan E^ye and 
Ear Hospital, X. Y. : Surgeon. Bronx 
Eye and Ear Infirmary, X. Y, 


Surgery Publishing Company 

New York 

November, 1921 

Dedicated to 
My Students and Teachers 



This book is a description of the procedure followed 
in a specialized form of nose surgery, the submucous 
resection of the nasal septum. Starting in the early 
years of the century with the operations worked out by 
Ballenger and Freer which supersede still earlier crush- 
ing operations, modifications in procedure have been 
introduced by the author and others working in this 
field. The pages which 'follow show that the changes 
have affected the technic of posture of surgeon and 
patient; the manner and method of anesthetization; 
and the use of specially designed instruments, to which 
the writer has contributed the Dunning curette 

The first five chapters of the book appeared first as 
a series of articles in the January, February and 
March, 1921, numbers of the American Journal of 
Surgery, They have been expanded, revised, and put 
in permanent form with the addition of three chapters 
dealing with case records, to meet requests from col- 
leagues and students. 

My special thanks are offered to Drs. Harmon 
Smith, Duncan Macpherson, and Wendell C. Phillips, 
for many helpful suggestions during the years in 
which the technic of the operation now used by the 
writer was in process of development. Dr. Iva L. 
Peters has also given valuable assistance in the criti- 
cism of the neurological material and in the prepara- 
tion of the manuscript. 

W. Meddaugh Dunning. 

Nczv York City. 



Preface v 


The Nose 

Important to humanity that the nose function prop- 
erly. Recent development of knowledge of its path- 
ology. Exposure to injury, by its prominence, 
cause of breaks, dislocations, etc. Deflection of 
septum often results. In recent years, many of 
these deviations from normal corrected by opera- 
tion. Purpose of this book to describe deviations, 
to indicate cases in which operation is necessary, 
and to describe operation. 

Anatomy of nose. Outer and inner parts. External 
wall important from surgical point of view. Rea- 
sons. Description of nasal septum. Its anatomy. 
Its vascular system. Its nerve supply. 


Breathing and Smelling 1^ 

Breathing and smelling the chief concern of the 
nose. Portal to the air passages. Exercises also 
partial control of taste and hearing. Connected 
with eye by tear duct. Nervous and circulatory 
relation. Normal potency of nostrils. Breathing, 
the chief concern of lower segments; smell, of 
upper segments. Air currents traced by writer in 
noses of silver polishers. Function of intranasal 
structures. Interdependence of smelling and breath- 
ing. Description of smelling process. Normal func- 
tioning of nose aids coordination between trunk 
and head. Sherrington's description of integrative 
function of olfacto-phrenic respiratory arcs. 



Common Septal Deviations IS 

Ideally the nasal septum is perpendicular. Among 
Caucasians, septal deflections extremely common. 
Definition of "deviated septum." Troubles result- 
ing listed. The writer believes the majority trau- 
matic in origin. Admits some "developmental." 
More among boys than girls. Among troubles 
caused by uncorrected deviations are hay fever and 
asthma. These diseases classified as "nasal reflex 
neuroses." Surgeon can help some cases. 
Attempts at classification of deviations. S-devia- 
tions, Z-deviations, and nondescript cases. De- 
scribed in order to work out method of procedure 
for simpler cases. 


Surgical Procedure in Submucous Resection of the 

Nasal Septum 27 

Procedure in uncomplicated cases described in this 
chapter. Operation outgrowth of work of Killian, 
Ballenger and Freer and others in early years of 
century. Technic perfected in last century by 
improvement in tools, modification of incision, care 
in selection of cases, and lessened time. Care of 
patient before operation. Method of anesthetiza- 
tion. Orientation of saturated plugs of great im- 
portance. Incisions: Hajek, Killian, Krieg, and 
others. Problem: to avoid scar tissue. Position of 
incision first used by writer after experiment with 
other incisions. Description of procedure in classic 
operation. Instruments used. After care of patient 
in simple cases. 


Special Surgical Procedure 61 

Unusual conditions sometimes present. Some non- 
descript deviations exhibit spur or ridge, with de- 
pression. Use of knife in this case described. 
Use of curette in cases of well-defined groove. Pro- 
cedure in cases where bone is involved. Removal 
of spur by forceps. Cases in which septum has 
been crushed. Fibrous tissue with adhesions pres- 
ent. Use of curette. Procedure with right-angled 
deviation with cul-de-sac. Use of needle and knot 
in case of fracture or tear. 



Typical Case Histories and their Significance 83 

Nervous conditions often present in cases of long 
standing structural alteration. Reeducation in 
breathing habits necessary. Operation necessary in 
twenty to twenty-five percent of cases. Seldom ad- 
vised for children. Cases of "shell-shock." These 
patients often inoperable. Case of fifteen-year-old 
girl. Operation necessary because of involvement 
of surrounding areas. Boy with septum fractured 
in forceps delivery. Patient with hyperesthesia. 
Two asthmatic cases of long standing. Indicate 
structural difficulty back of many cases of asthma, 
hay fever, and "rose cold." Nervous symptoms 
subsequent. Case of patrolman with ear affection. 
Cured by septal resection. Cases described show 
deviation a disturbing factor justifying operative 
procedure when other means fail. 


The Saddle-Back Nose 92 

This deformity sometimes result of faulty technic. 
Causes enumerated. Constitutional difficulty only 
reason why it should ever occur. Care in opera- 
tion. Watchfulness in after care. Cooperation of 


Conclusion 95 

Review and summary. Normal nose. Deviation of 
septum usually result of injury. Classification as 
result of observation of five thousand patients. 
Development of technic of operation a result of 
many years' practice in clinic and oflftce. Advice as 
to conservatism in choice of cases. Consideration 
' of personality of patient. After-care. Importance 
of nose and its function to individual happiness 
the chief reason of development of improved technic. 



1. Frontispiece. Specimen showing outer wall of 
interna] nose, illustrating turbinated bodies and 

2. Vertical sections through nose of a deer 5 

3. Diagram showing parts of septum 7 

4. Reproduction of an injected anatomical specimen 
from the author's collection showing circulation of 
the septum 11 

5. Diagrams of typical deviations 23 

6. (a) Instruments necessary in submucous resection 

of septum 31 

(b) Dunning's elevator 33 

7. Diagramatic representation of incisions, (a) Freer; 
(b) Yankauer; (c) Dunning; (d) Killian; (e) 
Hajek 35 

8. Drawing showing position of patient and scalpel 

at moment of incision 37 

9. Positions of curette elevator 41 

10. Curette scooping cartilage in cavity at beginning 

of operation 43 

11. Position of Ballenger swivel knife at point of en- 
trance 45 

12. Illustration showing use of punch forceps after re- 
moval of cartilage and starting removal of bony 
structure 47 

13. Continuing Figure 12, at late stage in removal of 
bone by punch forceps 49 

14. Diagramatic explanation of procedure with specu- 
lum and scalpel in place, in separation of mem- 


brane from bone on floor of nose preparatory to re- 
moval of portions of intermaxillary ridge 53 

15. Procedure with cbisel and mallet in removal of 
intermaxillary crest 55 

16. Later stage of procedure with mallet and chisel in 
removing portion of maxillary ridge 57 

17. Diagram showing completion of L incision 59 

18. Diagramatic drawing showing positions of Dun- 
ning's curette elevator in loosening membrane 
above and below spur 63 

19. Jansen-Middleton forceps biting away cartilage 
and bone above and below spur 67 

20. Punch forceps biting away bone and cartilage back 

of spur 69 

21. Removal of spur with curette 71 

22. Curette loosening membrane along groove 73 

23. Diagram showing curette scooping out cartilage on 
both sides of cul-de-sac 77 

24. Curette hooking cartilage at high point and re- 
moving obstruction 79 

25. Diagramatic drawings of procedure in closing 
perforation, showing position of needle and angu- 
lar forceps; also suture, together with knot used 

in tying silkworm gut 81, 



Fig. 1 — Specimen showing outer wall of internal nose, illustrat- 
ing turbinated bodies and meatuses; a. superior turbinate; h, 
superior meatus ; c, middle turbinate ; d, middle meatus ; e, ves- 
tibule ; /, inferior turbinate ; g, inferior meatus ; h, superior max- 
illa ; i, sphenoidal sinus ; j, orifice of Eustachian tube. 


It is a matter of lively interest to humanity that the 
nose do its work well. This interest is so great that 
it is strange to find that attention to the pathology of 
the nose is to a great extent a matter of our own gen- 
eration. In our older medical texts consideration of 
diseases of the nose covers not more than two or three 
pages. When many present-day practitioners were 
undergraduate students perhaps one-half of a lecture 
was devoted to the same subject. But with the accu- 
mulation of special knowledge of the past decades 
growing out of the increase in clinical instruction, a 
special technic and a rapidly increasing literature has 
come into existence. 

With the development of knowledge concerning the 
nose and its work came a realization that its promi- 
nence exposed it to injuries which became the source 
of other difficulties often not traced to their true 
source. Breaks, dislocations, and bruises, often looked 
upon, at the time, as negligible and of little moment, 
are later found to have caused blockages of the air 
passages which *have interfered with normal breathing 
and with the drainage of the sinuses, and have caused 
serious nervous difficulties. Among the chief causes 
of these difficulties are deflection of the nasal septum. 
The development of surgical technic has made possible 
the correction of many of these difficulties* v^\.tVv\!cv^ -ak^ 
of the knife. 


It is the purpose of this study to put into a perma- 
nent form the result of many years of study of the 
causes and results of deviations of the nasal septum, 
together with a description of the operation for relief 
from these deviations — the submucous resection of the 
nasal septum. Operations for these difficulties have 
been performed not more than twenty years. The 
operation is still classed as one of the most delicate and 
difficult of intranasal operations (Phillips,^ Porter,^ 
* Harmon Smith^). It therefore seems desirable to add 
to the information available the results of the writer's 
clinic and private practice in dealing with several thou- 
sand cases. 

In order to present more clearly the special study, 
we shall first consider briefly the normal nose, taking 
into account the pertinent features of its anatomy, 
physiology, and neurology. 

The nose consists anatomically of two parts : the 
outer nose; and the nasal cavities contained in the 
skull. The lower segment is the part concerned in 
respiration. In the upper part the cavities support the 
membrane containing the nerves of smell. Posteriorly 
the nose is continuous with the cavity called the naso- 
pharynx, the two openings into which are called the 
choanae. The bony frame of the nose is a part of the 
skull, but the outer nose is supported by bone above 
only; the rest of its shape is kept by cartilaginous 
structures varying with race and individual. The an- 
terior part of the nose is known as the ala or vestibule. 
This combination of bone and cartilage in the struc- 

* Phillips, Wendell C. : Diseases of the Ear, Nose and Throat. 
Philadelphia. 1919, 5th Ed., p. 536. 

* Porter, W. G. : Diseases of the Throat, Nose and Ear. 3rd 
Ed., revised under the editorship of A. Logan Turner, 1919, p. 

* Wright, Jonathan, and Smith, Harmon : A Textbook of the 
Diseases of the Nose and Throat. Philadelphia and New York, 


ture of the nose is of great importance, as we shall see 
in the study of fractures, dislocations, and deviations. 

The roof of the nose, which is very narrow, is 
formed on the external side by the ethmoid and behind 
by the sphenoid. It is here, through the cribriform 
plate of the ethmoid bone, that some twenty non- 
medullated nerves pass to supply the sensory organs 
in the olfactory mucous membrane. This area com- 
prising the olfactory sense, is very small, about five 
square centimeters in area, according to Watson, and 
consists of a small membrane lining the roof and sides 
of each nasal cavity. 

The external wall of the nose is the most important 
of its areas from the surgical point of view. Continued 
malformations of the septum react on this outer wall 
with grave results. This area is formed by the lateral 
mass of the ethmoid, the inner surface of the superior 
maxilla, the vertical plate of the sphenoid. To these 
outer walls are attached the turbinated bodies, struc- 
tures made up of thin osseous shell and covered by a 
vascular cavernous tissue possessing erectile tissue. 
These turbinated bodies project downward in such a 
way that the internal nose is divided into three cavities, 
or meatuses. There are usually said to be three of 
these bodies in the human nose, although by its lack 
of function and its difference in structure the body 
called the superior turbinate, situated quite above and 
behind and nearly always invisible, is perhaps ques- 
tionably classed as a turbinate.^ (See Fig. 1, also 
compare the drawing of the structure of a deer's nose. 
Fig. 2.) 

The region between the so-called superior turbinate 
and the roof of the nose is known as the "recessus 

* Douglas, Beaman : Nasal Sinus Surgery. Philadelphia, 1906, 
p. 18. 


spheno-ethmoidalis." Into the back of this recess the 
sphenoidal air sinus opens. Between the superior 
turbinate and the middle turbinate is the cavity con- 
taining the openings of the posterior ethmoidal air 
cells. The middle meatus, between the middle and 
inferior turbinates, is the largest of the three, and con- 
tains certain important processes. Here are the open- 
ing of the frontal sinus, that of the maxillary antrum, 
and of most of the anterior ethmoidal cells. Towards 
the front of this cavity is a ridge, the processus un- 
cinatus ; further back is a rounded elevation called the 
bulla ethmoidalis. Sometimes the bulla is so enlarged 
that there is the appearance of two turbinated bodies 
in this region, the outer being the bulla, and the inner 
the true middle turbinate. The bulla is probably a 
bone cell belonging to the ethmoidal system. 

The inferior meatus lies below the inferior tur- 
binate and extends to the nasal orifice. Its external 
wall contains the nasal duct, an opening through which 
a probe can pass to the lachrymal duct. This val- 
vular opening lies on the highest point of the external 
wall of the inferior meatus. The Eustachian tube 
leading to the ear lies just behind the posterior border 
of the inferior meatus, and is almost on a level with 
the posterior end of the inferior turbinate body. 

The nasal septum is the partition between the two 
nasal cavities, whose features we have just described. 
It is composed of a triangular cartilage, the "septal 
cartilage," with a supporting framework mode up of 
the perpendicular plate of the ethmoid above and of 
the vomer and the intermaxillary ridge below. This 
cartilaginous portion composes about one-third of the 
divisional area. It extends from near the junction of 
the nasal bones at their median line to a point near the 
tip of the nose, and is more or less intimately attached 

Fig. 2— Vei'liciil BfclioHM IIiiwikH ii 

Pig. S— DiHgram showing parts o( seplum ; a, triangular carti- 
lage : b, perpendicular plate ol the ethmoid ; c, vomer ; d. Inter- 
maxillary ridge ; e, crest of Intermaxillary ridge ; /, enlargement 
for triangular cartilage fitting Into the nioon-shuped groove o[ 


to the nasal cartilages, with an under surface extend- 
ing from near the nasal orifice along the ridge of the 
intermaxillary bone. (Fig. 3 — Construction of the 
septum.) Its posterior edge is attached to the vomer, 
and the perpendicular plate. The cartilage fits into 
the septal plate of the ethmoid, the vomer, and the in- 
termaxillary ridge by means of a groove, half moon 
in shape. (Fig. 3, F.) This joint-like surface is of 
great importance in the study of pathological condi- 
tions of the septum, as we shall later have occasion to 
show, for it is here that injuries cause significant al- 
terations. It should be noted that even with the ma- 
jority of normal noses the cartilage does not end with 
the smooth surface at the point of junction with the 
bones and groove, but sends out spurs, some normal, 
others individual or pathological. It is to this osteo- 
cartilaginous structure of the nasal septum that its 
many malformations are due, some of which involve 
the cartilage, the bone or both. 

The greater part of the septum is covered with a 
thick and highly vascular membrane made up of 
columnar epithelium with masses of embedded glands. 
The less vascular but more highly specialized olfactory 
membrane covers a limited portion of the upper part. 
Opposite or a little below the anterior end of the mid- 
dle turbinate there is a thickening on the septum re- 
sulting from an accumulation of glands. This is a 
danger point in the membrane, which is loosely at- 
tached to the septum, easily separable, and .as a result 
easily a seat of abscesses and hematomata. 

The nasal mucosa lines the nasal cavities proper 
but not the vestibule, which is covered by an invagina- 
tion of the true skin of the ala studded with hairs or 
vibrissae. This ciliated epithelium acts defensively 
against infection. The epithelium of the upper part 
of the nasal cavities, the olfactory t^^\ow/\% xvqxv-^'^\- 


ated, columnar, and highly vascular. Thus the pathol- 
ogy of the membranes of the anterior and upper parts 
of the nose is quite distinct. 

The vascular system of the nose is in close relation 
with the intracranial circulation. While there are 
idiosyncratic differences in individuals, it has been the 
observation of the writer that the greater part of the 
septal circulation comes from above. (Fig. 4.) The 
nasal branch of the ophthalmic artery supplies the 
upper part of the septum; the septal branch of the 
labial artery and a small branch from the facial artery 
supply the anterior part of the septum. In addition, 
the two naso-palatine arteries, derived from the in- 
ternal maxillary artery, follow the course of the naso- 
palatine nerves as they pass along the sides of the 
vomer and enter the septal ridge. Some of the cor- 
puscular elements of the blood exude from the capil- 
laries to the surface of the glandular epithelium and 
aid in moistening the inspired air. 

The nerve supply of the nose is equally extensive 
with that of the circulation. This has its unfortunate 
results as well as those more beneficent, for the nose 
is the source of innumerable reflexes. The naso- 
palatine nerves enter the septal ridge through the 
foramina of Scarpa, where they are so deeply pro- 
tected by bony canals that it is difficult to reach them 
by anesthetic. 

This brief outline of the structure of the nose indi- 
cates that we are dealing with a highly complex organ 
which because both of structure and location is pe- 
culiarly liable to derangement of function. These 
functions, of smelling and breathing, are of such para- 
mount importance in the physical and mental integra- 
tion of the organism that we shall deal with them 
briefly before taking up the consideration of the 
pathology of the nasal septum. 



The nose forms the chief portal to the air passages. 
In fact, it is with the mouth the forefront of the pas- 
sages leading to the chief thoracic and abdominal vis- 
cera. It exercises a high degree of control over the 
senses of smell, taste, and hearing. Of the sense of 
taste, it may be said that it is often true that what we 
think we taste, we smell. The sense of smell is buried 
deep in the nose. The Eustachian tube leading from 
the ear to the recesses of the nose, connects the sense 
of hearing with the functioning of the nose. It is also 
connected with the eye by the nasal duct and by close 
nervous and circulatory relationship, a relation so close 
that it is estimated that a very large percentage of eye 
troubles originates in the nose.^ It therefore becomes 
evident on even cursory consideration that we moderns 
have been prone to underestimate the contribution of 
the nose to our power to adapt ourselves to the world 
in which we live. It has been estimated that by our 
neglect to cultivate the sense of smell we have lost by 
a third the power to remember. Doubly unfortunate, 
then, are those who by malformation are incapable of 
using this organ to their health and advantage. It 
would seem to be a matter of personal welfare to culti- 
vate this organ, which somehow fell into bad repute, 
to keep it in good condition, and to restore it when it 
has lost its power of normal functioning. 

1 Thomas H. Curtin. M. D.. quoted from lecture delivered on 
March 5, 1916, before The Lighthouse, N. Y. Ass'n for the Blind. 



Normally, the nostrils are open. This patency is 
constant, and can be increased in forced expirations by 
the action of the musculo-cartilaginous structure of 
the alae, which constitute in part a dilator apparatus. 
Subjects with over-thin nostrils often have respiratory 
difificulties. This is especially the case when there is 
in addition a septal deviation. Atrophy of the struc- 
ture of the alae may be accompanied in such cases by 
hypertrophy of the dilator and contractile muscles at- 
tached to the upper cartilaginous tissues. 

The region of the nose chiefly concerned in breath- 
ing is its lower segment, the part of it below the 
lower border of the middle turbinate and above the 
floor of the nose. In inspiration the greater part of 
the function is carried on between the lower border of 
the middle turbinate and the lower border of the lower 
turbinate; in expiration, the greater part of the air 
comes out through the inferior meatus. That this is 
true is illustrated by the difficult expiratory breathing 
when we have enlargement of the posterior tip of the 
lower turbinate. The writer has observed the truth 
of these statements in his dealings in New York clinics 
with silver polishers from the great hotels, in whose 
noses the path of the air currents is clearly marked by 
the shadings resulting from the polish they have in- 

The functions of the intranasal structures in the 
breathing process seem to be to warm the air, to 
moisten it, and to cleanse it by the action of the 
vibrissae of the ciliated epithelium. Although there 
seem to be air paths, as we have indicated, with eddies 
in the currents set up by individual peculiarities in 
shape, it may be said that all the surfaces of the nasal 
cavities come in contact with the inspired air. An ex- 
ception to this statement is found in the olfactory 


region, which, while not closed off from the impact, is 
sheltered from direct impact by its position high in the 
nose. Since olfaction is carried on in the upper part 
of the nasal cavities, it follows that an obstruction in 
the upper part of the nose will affect smell. For the 
same reason, since respiration is carried on in the lower 
region of the nose, the high obstruction will not at 
the outset affect respiration. 

Smelling cannot be carried- on independent of breath- 
ing, although the inferior or lower part of the nose is 
chiefly concerned in the one case and the superior or 
upper part in the other. On the contrary, smelling is 
dependent upon breathing. Before the scent of any 
object can be detected the scent-laden particles of air 
must go through the narrow slit between the middle 
turbinate and the septum known as the sulcus olfac- 
torius. (See the drawing of the deer's nose. Fig. 2.) 
This narrow passage is the gateway to the sensory 
area of the nose, itself a small saddle-shaped mem- 
brane lining the roof and sides of the upper nasal 
cavity and out of the direct path of the air-currents 
which lead to the posterior part of the nose. 

In order to produce an olfactory response the 
odoriferous substance must be placed in the field from 
which the air is inspired. The olfactory cell bodies lie 
in the sensory membrane, the peripheral process of 
each cell consisting of a number of hair-like structures 
which project into and slightly beyond the membrane. 
The other end of the cell gives rise to the nerve fiber, 
which can be traced upward through the sponge-like 
bone of the cribriform plate to end around cells situ- 
ated in the olfactory bulb of the brain. 

The olfactory bulb and tract lie beneath the sulcus 
rectus on the frontal lobe of the brain. The studv of 
comparative anatomy gives phylogenetic evidence that 


the first stages in the development of the cortex 
cerebri occurred in connection with the distance recep- 
tors for chemical stimuli, that is, in connection with 
sensitiveness to smells. The olfactory apparatus even 
in mammals exhibits a neural architecture of primitive 
pattern. The cell which conducts impulses to the brain 
from the olfactory membrane in the human nose re- 
sembles cells in the skin of the earthworm in that its 
cell-body lies actually amid the epithelium of the skin- 
surface and is not deeply buried near or in the central 
nervous organ. Moreover, one and the same cell by 
its external end receives the stimulus and by its deep 
end excites the central nervous organ. ^ 

Minute particles by their impact upon the termini of 
the olfactory nerve processes produce the sense of 
smell. These receptors react to every minute chemical 
stimulus, probably gaseous particles given off from the 
stream of inspired and expired air coming into contact 
by diffusion with the olfactory membrane. The chem- 
ical stimuli to which the receptors for smell react are 
for some substances from 1 to 20,000 percent more 
sensitive than those of taste, although Zwardemaker*s 
olfactometer shows marked variability in individual 
threshold capacity, with a lowering of the threshold in 
fatigue in many cases very marked. Hysteria and 
neurasthenia play their part in disorders of this sense 
as in the case with other faculties. 

This brief description of the nose and its work is 
given in part to help us visualize the nose as one of the 
main receptive organs providing data for the rapid 
and accurate adjustment of the human animal to con- 
ditions of time and space, and to show more clearly the 
need for care in the preservation of the functions so 

* Sherrington, Charles S. : The Integrative Action of the 
Nervous System. Lecture IX. See also Sherrington's article on 
"Brain," 11th Ed.. Encyclopaedia Britannica. 


necessary not alone to happiness but to health. A 
normal nose aids in the coordination of the activities 
of the trunk with the requirements of the head. Sher- 
rington calls attention to the fact that the olfacto- 
phrenic respiratory arcs exemplify the integrative 
function. The nerve fibres from the cephalic receptors 
end in the grey matter of the central nervous axis not 
far from their own segment. Thence the conducting 
arc is continued backward by another strand of fibres, 
and these reach the mouths of the final common paths 
in the grey matter of segments of the spinal cord. The 
ramifications of the neurones attached to the smell 
receptors are so extensive and the reactions they excite 
are so far-spreading that their association with the re- 
actions and mechanisms of other receptors is especially 
wide-spreading. It is for this reason that the training, 
or perhaps better the reclamation of the sense of smell 
can affect the memory and bring back from the uncon- 
scious so much of the past. 


Ideally, the nasal septum is perpendicular. As a 
matter of fact, among individuals of the Caucasian 
race, it is seldom quite median. If any judgment can 
be based on the number of applicants for correction of 
deflections, it may be said that negroes are compara- 
tively free from such deviations. Morell Mackenzie 
found that asymmetry existed in nearly seventy-seven 
percent of 2,000 Caucasian skulls examined. It is the 
opinion of the writer from his observation of cases 
entered in New York hospitals that fully seventy-five 
percent of all cases entered present septal deformities 
of more or less serious character. 

In general, when we speak of a "deviated septum," 
we mean the exaggerations of the departure from the 
median which are pathological or obstructive. So long 
as the deviation is slight and causes no interference 
with breathing or with drainage from the sinuses, it is 
of little importance except perhaps from an aesthetic 
standpoint. Only deviations so pronounced and 
pathological as to call for surgical interference are the 
subject of this study. Among the chronic troubles re- 
sulting from their neglect are the following: Inter- 
ference with breathing, obstruction of the drainage of 
the sinuses, pharyngitis, laryngitis, and catarrh of the 
middle ear. Ear difficulties almost always occur on 
the side on which there is interference with breathing. 


when the difficulties are the result of septal deviations. 

In a consideration of the etiology of septal devia- 
tions, the writer as a result of his own observation 
finds himself in agreement with Killian that the ma- 
jority of those calling for surgical procedure are trau- 
matic. There are others, however, which can be 
grouped under the descriptive term "developmental."^ 
In the absence of a definite history, such a distinction 
is difficult. Except in the case of bowed deviations 
associated with a high arched palate, it is very prob- 
able that many supposedly developmental deviations 
are actually traumatic. This would be more true of 
boys than of girls because of the more violent sports 
of boyhood. There can be little doubt that with the 
extension of the present movement for the physical 
examination and care of school children, a connection 
will be uncovered between these deviations and re- 
tardations in development, but too early operation on 
growing children for such difficulties is to be depre- 
cated. Such operations should be deferred until they 
have reached fourteen years or even later. 

As it has been found that the resection of the sep- 
tum relieves an imposing number of cases of hay fever 
and asthma, the writer ventures into this perplexing 
neurological field. In a general way, these diseases 
are classified as nasal reflex neuroses in which there 
is present hyperesthesia of the nasal mucous membrane 
— probably in the ethmoid region. 

The work of Pavlov, Bechterew, Cannon, Crile and 
others has placed on a scientific basis "what has been 
known empirically for centuries, that emotional factors 
are capable of producing acute as well as structural al- 
terations * * * as well as being constantly opera- 

^ Porter, W. G. : Diseases of the Throat, Nose and Ear. 3rd 
Ed. Revised under the editorship of A. Logan Turner, 1919. 
p. 121. 


tive in causing so-called functional disease."^ 

Neurologists hold that asthmatic attacks may have 
their exciting causes at any one of the three levels, 
physico-chemical (autonomic), sensori-motor, or 
psychical. On the sensori-motor level the inducing 
cause may be pressure on laryngeal or bronchial 
nerves, or reflexes from the nose. The problem there- 
fore in treating asthma is first to find which level is 
chiefly involved. It is here that a future lies for inter- 
relational therapy. It is possible that such bafiling dis- 
orders as horse and cat asthma may derive their 
psychogenic etiological factors from the unconscious 
odor associations to which we have already referred 
(Chapter II). A union of forces among the branches 
of medicine and therapy will accomplish much to clear 
up such obscure cases and give relief to the unhappy 
victims. But before that time comes the surgeon has 
it in his power to benefit many cases. In narrow noses 
dust particles, steam heat, tobacco smoke, and other 
like irritations increase the hyperesthesia. It is a mat- 
ter of record that there have been more nasal difficul- 
ties since the building of the New York City subways, 
with their dust and stale air. In order to properly 
treat these cases free passage for air through the nose 
must be provided, and this often calls for the correc- 
tion of septal deviations. 

Various attempts at classification of septal devia- 
tions have been made. In view of the fact that so 
many of the deviations are traumatic, it is evident that 
we are dealing with such variables as the direction of 
the original blow, the resistance offered, the location 
of the trauma, the age of the victim, etc. We shall en- 
deavor to clarify our description by classifying devia- 

1 Jelliffe, Smith Ely, and White, Wm. A. : Diseases of the Nerv- 
ous System. 3rd Ed., 1919, p. 122. 


tions as (1) bowed or curved, and (2) angular. To 
aid in visualizing them they may be called S-deviations 
and Z-deviations, picturing these letters as crossing 
the median line of the septum. Such a rough general 
classification is an attempt to distinguish between the 
results of fracture and bending. It is evident that 
traumatic cases would most often fall among the Z- 
deviations, while the S-deviations would include along 
with traumatic deviations the greater number of so- 
called developmental deviations. There are, however, 
nondescript cases in which the bone. and cartilage have 
been so injured and dislocated by the blow as to fall 
under neither of the suggested headings. Because of 
their special problems we shall later describe the sur- 
gical procedure necessary in dealing with such cases. 
When we recall the distribution of function among 
the anterior and lower part of the nose, the posterior 
part, and the upper part, it will be evident that high 
deviations of either class do not cause interference 
with breathing experienced by those who have obstruc- 
tions in the lower or anterior part of the nose. These 
anterior obstructions, some of which are almost hori- 
zontal, turn the air currents from their accustomed 
paths. In many of the S-deviations we find deflec- 
tions of both bony and cartilaginous portions of the 
septum, many of them more marked anteriorly and 
curving out toward the turbinates in such a fashion as 
to interfere seriously with normal breathing. (Fig. 5-a.) 
In such a type the lower part of the curve is often 
sharper, causing greater difficulty with this function 
than in the case of the upper curve. It is the higher 
curve that interferes with drainage and that is more 
apt to cause nervous symptoms. The line of deflection 
in these S-deviations is anterior-posterior, or along the 
perpendicular line, instead of being almost horizontal 


as in many of the Z-deviations. In crossing the me- 
dian line the deviation causes the blocking of both pas- 
sages, with a marked low obstruction on the one side, 
a slighter high obstruction on the other. The varia- 
tions in the S-type are not apt to be so extreme as in 
the Z-deviations, although the reservation must be 
made that there have been cases observed by the writer 
of the S-type which were so twisted as to approach 
the horizontal rather than the perpendicular plane. 
Because the S-deviations are more often true to type 
they form the basis for the operation described in 
Chapter IV. The special procedures will be described 
in Chapter V. 

The angular, or Z-deviation, is an exaggeration of 
the curved or S-deviation, and presents more anoma- 
lies. As in the S-type, the anterior deflection is more 
marked and is apt to be sharper than the posterior de- 
flection. The original trauma may have resulted in 
fracture, with dislocations, blood clots, etc. (Fig. 5-^.) 
These deviations are frequently associated with crests 
or ridge on the septum, usually a little above the floor 
of the nose and commonly along the line of the junc- 
tion of the intermaxillary ridge, the triangular cartilage 
and the vomer, running upward and backward from 
the nasal spine. These ridges are sometimes very 
large, extending into the nasal cavity so far that they 
are in contact with the lower end of the inferior tur- 
binates. They may be bony or cartilaginous or both, 
and always present difficulties in surgical procedure. 

The muco-perichondrium covering the septum is 
normally easily separable from the septum. Its point 
of least resistance to injury is near the center. If a 
fracture occurs at this point it is often followed by 
hemorrhage. In the healing process the clots fre- 
qucntly become the centers of growths and adhesions. 


themselves obstructions and centers for further ab- 
normal growths as time goes by. These thickenings 
and adhesions, accompanied by tension of the mem- 
brane, are the source of operative problems. The 
membrane on the convex side is liable to atrophy, as in 
the case of all convex surfaces. 

It is evident that the Z-deviations are more involved, 
present more anomalies, and call for more variations 
in surgical procedure. In one of the more common 
variants of this type there is a low angular deflection 
which crosses the median line low in the nose at what 
approaches a right angle, returning to the perpendicu- 
lar posteriorly with a wider angle. (Fig. 5-d.) 

In both the S-deviations and the Z-deviations, as a 
rule, a low ridge obstructs the inferior and middle 
meatuses on the narrow side, while the other side is 
left too wide open, with the result that the inferior tur- 
binate is often enlarged. The upper bend often forces 
the midddle turbinate outward, thus causing obstruc- 
tion to the drainage of the superior meatus and acces- 
sory sinuses. The lower part of the deviation presses 
against the inferior turbinate anteriorly, not as a rule 
posteriorly, while the upper curve presses against the 
middle turbinate anteriorly or for nearly its whole 
length. The posterior part of the obstruction is often 
bony and is usually covered with cartilage, while the 
spurs also are both bony and cartilaginous. 

There are cases in which the force of the original 
blow was great enough to dislocate the septal cartilage 
from the moon-shaped groove into which it was origi- 
nally fitted. The cartilage would then fall on one side 
or the other of the ridge, depending on the direction of 
the blow, and the groove would gradually be filled in 
with fibrous tissue. (Fig. 5-r.) Another result of 
this dislocation would be thickening and spurs, with an 


elongation of the cartilage. Cases of curved devia- 
tions 'accompanied by a sharp spur and a groove are 
especially difficult from the surgical point of view be- 
cause of the danger of tearing the membrane. 

Sometimes the septum has been torn loose in the 
anterior portion and pressed to one side. (Fig. 5-d.) 
As a result of such a dislocation part of the cartilage 
often lies in a position approaching the horizontal 
across the inferior meatus. Part of it may cross the 
median line and partially block the vestibule of the 
open side of the nose. In a good many of such cases 
the dislocated portion of the cartilage is separated from 
the rest of the septal cartilage by the fracture, the gap 
between the parts being filled with fibrous tissue. This 
creates a difficult situation and necessitates a variation 
in the technic of the ordinary operation. 

It is not to be understood that this chapter has 
exhausted the possible varieties of classification of 
septal deviations. All that has been undertaken is to 
simplify the description of the results of trauma and 
resultant malformation in order to work out a method 
of procedure for the simpler cases, which can be modi- 
fied to fit the less ordinary cases. With these facts in 
hand the procedure in the classic operation for curved 
or S-deviations will be better understood and more 
easily modified to meet involved situations. 



The operation now most frequently used for correc- 
tion of the deviations of the nasal septum which we 
have described in Chapter III and which are remedi- 
able by surgery is an outgrowth of the work of Killian, 
Ballenger, Freer, and others in the early years of this 
century.^ In the last decade the technic has been 
perfected by improvement and adaptation in the tools 
used, by modification of the incision as the result of 
experience, greater care in the selection of cases, and 
a lowering in the time of the operation. Operators 
specializing in this field lay increased emphasis on a 
knowledge of the anatomy, circulation, and neurology 
involved in a favorable prognosis. It is because of 
progress in these interrelated fields that the technic 
of this operation has reached the stage of perfection 
now attained. 

The present-day submucous resection operation 
superseded the earlier crushing and sawing operation 
of Asch and others. The older operations were pro- 
ductive of great shock with consequent traumatic dis- 
turbances, sometimes of long continuance. They were 

* See Ballenger, Wm. L. : Diseases of the Nose, Throat, arid 
Ear. 4th Ed., Phila. and N. Y.. 1908. Article by same writer. 
The Submucous Resection of the Septum Arranged by Steps. 
The Laryngoscope, April, 1906, Vol. XVI, No. 4. 

Freer, Otto T. : The Correction of Deflections of the Nasal 
Septum with a Minimum of Traumatism. Reprint, Journal of 
the American Medical Association, March 8, 1902. 


too often followed by hemorrhage, and destroyed ex- 
cessive amounts of membrane with the consequent 
pathologic phenomena of scar tissue and poor drain- 
age. The post-operative treatment by plugging was 
painful and sometimes indefinitely prolonged. 

The septum of the nose as we have said in Chapter I 
is composed of the triangular cartilage, the perpen- 
dicular plate of the ethmoid, the vomer and the inter- 
maxillary ridge. The triangular cartilage rests in 
grooves in these bones. Along the ridge of the 
nose it lies between the lateral cartilages. The part 
that extends down toward the end of the nose is prac- 
tically without attachment. It is generally along the 
moon-shaped groove that injuries to the septum cause 
significant alterations ; and it should be noted that 
the cartilage sometimes sends out spurs from the 
grooves, some apparently normal, others individual and 
pathological. The posterior edge of the septum is 
attached to the vomer, while the tip of the nose and 
the nasal ridge are the limits of the under surface. 
This septal cartilage is covered with a highly vascular 
mucous membrane of columnar epithelium. The area 
has an abundant blood supply, part from the naso- 
palatine arteries, from the nasal branch of the ophthal- 
mic artery, the septal branch of the labial artery, and 
from a small branch of the .facial artery which per- 
forates the nasal bone and further supplies the anterior 
part of the septum. Because of the extent of the blood 
supply there is little danger of the parts becoming 

The indications calling for operative procedure in 
deviations of the septum have already been /described 
in Chapter III. The procedure described in this Chap- 
ter is observed in ordinary cases of curved or S-devia- 
tions, with no sharp angles. The operation calls for 


local anesthetization and is usually performed with the 
patient in a sitting posture. The following instru- 
ments are necessary ; a reflected light ; a small scalpel ; 
a nasal speculum ; a packing speculum ; Dunning's com- 
bination curette elevator; a Ballenger swivel knife; 
punch forceps (two styles) ; a small chisel and mallet.^ 

The patient should have spent thie previous night 
in the hospital or under equally quiet conditions. After 
a good meal, preferably an hour and a half to two 
hours before the operation, he is seated and his nose 
cleansed for anesthetization. It is impossible to 
cleanse the nose thoroughly because of the many 
openings, but we are aided by the fact that the nose 
is singularly free from infection. Unless there is 
indicated some idiosyncrasy to cocaine, that drug is 
used as an anesthetic. A nervous condition in the 
patient will predispose to cocaine poisoning; for this 
reason the writer prefers a weak solution, about equal 
parts of cocaine, ten percent, and adrenalin chlo- 
ride 1-1,000. If anesthetization takes longer than the 
average of about twenty minutes, weaken the solution 
to four percent. Ballenger and Freer reduced the 
time for anesthetization by the use of pulverized co- 
caine with a 1-2,000 solution of adrenalin. This re- 
duces the time; but the writer believes that many of 
his colleagues will agree that the economy of time is 
made at the grave danger of cocaine poisoning from 
drifting crystals, when the powdered cocaine is used. 

Complete and speedy anesthetization may be in- 
duced by care in the placement of the saturated plugs. 

1 Yankauer says that the ingenious Ballenger swivel knife like 
the original cartilage knife of Killian, leaves a strip of cartilage 
on the crest. To obviate this he uses a hook-shaped separator, 
with a pair of forceps with hollow blades to cut the cartilage. 
The writer has found that this strip presents no particular diffi- 
culty, as it can be removed with ease by a curette. In later 
operative work he has used a heavier chisel and mallet than in 
earlier years. 


Place the first plug, thoroughly moistened, high under 
the superior turbinate. This is often difficult because 
of the shape of the nose. Lay the next plug above 
the lower turbinate and on the middle turbinate. Place 
the third as far underneath and posterior to the lower 
turbinate as it can be placed, well back toward the 
pharynx, leaving a generous length to fill the anterior 
part of the nose. The skin of this part of the nose is 
affected through the circulation. Injection is never 
necessary if adequate time and care are given to this 
stage of procedure. 

Much of the success of .anesthetization is dependent 
on the careful orientation of these saturated plugs. If 
we recall the nervous system of the nose we know we 
are to reach the nerves above coming in from the cribri- 
form plate as well as the ganglia of the spheno-palatine 
system. The second and third packings are so placed 
as to carry the cocaine posteriorly. In that region the 
septum is completely covered, and is bleached and 
hardened by the process to the consistent texture of a 
linen handkerchief, or perhaps better, of a tanned hide. 

After anesthetization is complete, the plugs are re- 
moved and the surgical procedure is initiated by in- 
cision. For convenience and therefore for speed and 
dexterity, the incision is made on the left side. 

Much of the content of the earlier literature deal- 
ing with this operation on the septum is devoted to the 
character and position of the incision, or incisions. 
The old incision made at the tip of the nose is known 
as the Hajek incision (Fig. 7) ; the one at the junc- 
tion of the vestibule skin with the mucous membrane, 
the Killian incision. The latter incision was used by 
Ballenger except when the septal cartilage was de- 
flected at the tip, when he used the Hajek incision. 
Krieg had made a U-shaped flap with three incisions. 








Fig. 7 — Diagrammatic representation of incision ; a. Freer ; h, 
Yankauer ; c. Dunning ; d, Killian ; e, Hajek. 


Pig. 8 — Showing position of patient and scalpel at moment of 



But observation of the secondary results of this opera- 
tion showed that the problem was to avoid scar tissue 
that would interfere with one of the main functions of 
the septum, to facilitate the drainage accomplished by 
the capillary attraction between the secretions and the 
ciliated epithelial surfaces. If a thick horizontal band 
of squamous epithelium is formed by the operation, 
the flow of mucus is impeded, dries, and forms crusts. 
This called for the reduction to a minimum of the 
amount of scar tissue. Other modifications of the 
earlier incisions were concerned with the avoidance 
of perforations. It had been found that the largest 
number of these perforations had taken place with the 
flap incision. Hajek had made a single curved in- 
cision in the mobile septum along the anterior edge of 
the cartilage ; but his operation left the dorsum of the 
nose supported by a strip of cartilage whose only at- 
tachment, the notch between the nasal bones, was 
very weak. Killian had made a curved incision in 
front of the deviation with the convexity forwards. 
But in the more severe deviations the management of 
the lower part of the septum is "most difficult," to use 
his own words. 

Years of operating have taught the writer that the 
most successful operations result from a vertical in- 
cision anterior to the white line appearing very dis- 
tinctly in the anesthetized nose, at the point of junc- 
tion between the mucous membrane and the true skin. 
This line, anterior to the Killian incision, is used as a 
guide in order to get a tougher membrane and to re- 
move the anterior deviations if they exist. 

In making this incision, the knife is inserted through 
the mucous membrane, to, but not through the carti- 
lage. The cut is started about one- fourth of an inch 
from the roof of the nose, and prolonged downward to 


the floor and outer wall, the deep L-incision being com- 
pleted at the close of the operation for drainage pur- 
poses, and to lessen the danger of atresia. (Fig. 8.) 

The incision made, we elevate the muco-perichon- 
drium from the cartilage by the use of the curette end 
of the elevator. This blunt instrument is safer, in 
order to avoid tearing. Starting at the highest angle 
of the incision and changing to the. flat end of the 
elevator, we push gently backward, upward, then 
downward. (Fig. 9.) In the majority of cases we 
are able to separate the mucous membrane from the 
cartilage, and from part of the perpendicular plate of 
the ethmoid with this stroke from behind forward. 
Then scraping through the cartilage at a point posterior 
to the incision and near the lower limit of the cartilage, 
as illustrated in Figure 10, turn the curette so that its 
back lies on the membrane of the other side and scoop 
out the cartilage by a forward and upward stroke. 
This process should be completed along the line pos- 
terior to the incision in order to avoid perforation op- 
posite the incision at that point, if one is so unfor- 
tunate as to go through the membrane of the opposite 
side. The next stage is the complete separation of the 
muco-perichondrium from the septum on the opposite 
side, with the same procedure. When this is done the 
deflected cartilage may be removed either with the Bal- 
lenger knife or with forceps. (Fig. 11.) The operator 
should use great care at this point to avoid any use of 
force, in order not to dislocate the septal cartilage 
from the lateral cartilages or at the junction of the 
perpendicular plate of the ethmoid. These aid in the 
formation of the bridge of the nose. 

If the deformity is not corrected by the removal of 
the cartilage in the way described, a cutting forceps 
is next inserted through the incision. Bite with this for- 

Fig. 9— Showing posHloiis oC curette elevator; 1. cut 
2. elevator end; dotteii line of dlrcetlon wHh arrowa 
direction taken by liistrunient In loosening membranes 

Fig. 10 — Showing curette scoopiiij:: carliliiKC in caviiy at he- 
ginning of operation. 



Fig. 11 — Showing position of Ballenger swivel knife at point 
of entrance. Dotted line shows direction tal^en i)y knife. 





ceps through the junction of the perpendicular plate 
of the ethmoid with the cartilage at the highest point. 
(Fig. 12.) The surgeon must exercise great caution 
at this point to avoid fracture of the cribriform plate, 
— a danger against which one can easily guard. The 
perpendicular plate of the ethmoid and any part of the 
vomer causing obstruction is removed (Fig. 13) with 
the aid of a punching forceps. The incisor crest 
usually causes more or less obstruction; here also is 
often found a large amount of fibrous tissue and ad- 
herent membrane, especially at the junction of the 
perichondrium and the periosteum. After the carti- 
lage lying above is removed, these may be separated 
by a sharp knife, if one will remember to keep the 
sharp edge of the knife on the incisor crest. (Fig. 14.) 
The incisor crest is then removed with a chisel and 
mallet. It should be remembered that the incisor crest 
extends well forward; if, therefore, the chisel is in- 
serted well down on the crest and driven upward it 
will separate with the exertion of very little force. 
(Fig. 15.) 

On the removal of the incisor crest, together with 
the other bony and cartilaginous portions of the sep- 
tum, there is left a roomy opening between the mem- 
branes. The operator has now to deal with the inter- 
maxillary ridge, which is thin below its junction with 
the triangular cartilage. If the chisel is inserted so 
that it reaches the ridge, with one or two slight taps 
the bone can be fractured for considerable distance 
posteriorly. (Fig. 16.) It is then easily removed with 
a curette or with forceps. 

The division of the membrane is now continued at 
its outer angle for a little more than one-third of an 
inch, posteriorly, to facilitate drainage and relieve 
danger of atresia. The sae \s tVvoTO>3i^c^N ^^•^cwt.-^vS.^ 


the blood clots and any remaining pieces of cartilage 
and bone are removed. Replace the mucous mem- 
brane on the septum. The septum is lined to see if 
there is any remaining deviation ; if not, the membrane 
is replaced in position. (Fig. 17.) It will be found that 
the membrane has contracted ; because of this there is 
but little danger of hematoma. The healing process 
will be aided by the drainage of the end of the L-in- 

The surgical procedure in an uncomplicated case of 
curved deviation is now complete. The nares are 
packed with* vaseline gauze, which is left in place for 
twenty-four hours. Care should be exercised in pack- 
ing that the gauze is placed not too far posteriorly, in 
order to avoid irritation of the Eustachian tube and 
also to avoid follicular tonsillitis. After the removal 
of the gauze, the patient is instructed to insert white 
vaseline in the nose. A few crusts will form ; these 
should be removed about once a day. There is little 
reaction from this operation, and the patient is usually 
able to return to his ordinary pursuits in about forty- 
eight hours after the packing is removed. 

Fig. 14 — Diagrammatic explanation of procedure with specu- 
lum and scalpel in place in separation of membrane from bone 
on floor of nose preparatory to removal of portions of incisor 
crest and intermaxillary ridge. 


Fig. 15 — Showing procedure with chisel and mallet in removal 
of incisor crest. 


QC "■ 




Fig. 16 — Showing later stage of procedure with mjillet and 
chisel in removing portion of intermaxillary ridge ; 1 and 2, show 
instrument's change of position — chisel not driven so far usually, 
as indicated in diagram. 

Fig. 17 — Diagram allowing comph.-t ion of L-inoision. 





In the previous chapter we have described the surgi- 
cal procedure to be followed in the more typical cases 
of septal deviations. But in these cases, as in all op- 
erative work, the surgeon often finds unusual condi- 
tions which tax his skill and ingenuity. Some of these 
exceptional cases occur frequently enough in a long 
experience to establish a procedure that may itself be 
standardized. We shall describe some of these cases, 
with suggestions as to ways to meet the special condi- 

There are deviations of the nondescript type which 
exhibit a well-marked spur or ridge. In these cases it 
will be found that the septum after being thrown out 
of the normal position has bowed, so that it is convex 
on one side, and more or less concave on the other. 
These spurs commonly have at their extremities well- 
defined crests. On the concave side, toward the ante- 
rior part of the nose, there is more or less of a gutter, 
the depression becoming more marked in the posterior 
region. This ridge and depression are found to ex- 
tend back in most cases over about two-thirds of the 
length of the septum. 

In special cases of this ridge and depression type, 
the incision is made at the usual position, as described 
in Chapter IV. If the concavity of the septum occurs 
on the left side, the muco-perichondrium is first sep- 
arated from the crest very carefully with a small knife 
of the Ballenger type. The original incision is then 


prolonged to the outer side of the nose near to and a 
little forward of the lower tip of the inferior turbi- 
nate, as in the regular procedure. The flap will then 
lie at an acute angle, leaving abundant space — a very 
necessary requirement in these cases calling for extra 
caution. The loosening of the membrane should be 
done with great care, using the curette end of the 
elevator, as illustrated in " Figure 22, and separating 
very gently with an outward motion from the gutter, 
at the same time keeping the curette in the groove. 
The greatest caution will be found necessary at the 
point of deepest depression, usually opposite the sharp- 
est point of the spur and in a posterior position on the 

Such is the procedure when the ridge lies on the 
left side. In dealing with cases presenting a well-de- 
fined groove on the right side, remove with the curette 
a part of the cartilage just behind the original incision, 
separate on the concave side, and proceed as before. 
It is a matter of observation that these spurs are found 
on the right side in the greater number of cases, and 
if we recall that they are traumatic in origin the rea- 
son is evident because of the ordinary incidence of 
blows from a human source. 

After the removal of the anterior portion of the 
cartilage, it is well to continue the separation higher up 
with the curette end of the elevator. There is less 
danger of tearing th.e membrane with this instrument. 
(See Fig. 18, first position.) Then, changing to the 
other end of the elevator, continue the separation by 
pushing gently upwards and backwards. There will 
usually be little difficulty in separating the membrane 
down to the point on the spur where the convexity is 
causing tension with consequent thinness of the mem- 
brane. (See second position, Fig. 18.) 

Pig. 18 — Diagrammatic drawing sliowing positions of l")un- 
ning's curette elevator in loosening nicnibrano abovo and below 



In the majority of these cases with the spur and 
ridge, posterior to the sharpest point of the deviation 
the septum after a gentle curve falls back to the per- 
pendicular. In such noses, smell may be fairly normal 
except from some secondary difficulty, but breathing 
is apt to be seriously interfered with. This is because 
usually the bone behind the spur was not affected by 
the original injury. But in cases where the bone is 
affected, the cartilage and bone high up and near the 
spur may be removed by inserting the Jansen-Middle- 
ton forceps and biting them away, as illustrated in 
Figure 19. This procedure will relieve the situation 
above the spur. Then take the forceps, go in back of 
the spur and press down gently. This gentle down- 
ward pressure will separate the membranes, which are 
usually loosely adherent posterior to the spur. This 
will also break down the posterior attachments of the 
spur, which, as a rule, extends from a position near 
the floor in the anterior part of the nose upwards and 
backwards for a distance nearly half the length of the 
septum. The situation has so far been relieved back 
of the spur. We now start in front of the spur and 
near the floor of the nose to separate up to where the 
mucous membrane thins again. Bite through at that 
point with the forceps. (Fig. 20.) By this time 
the spur is so completely loosened that a gentle push 
with the curette to the concave side will cause it to 


separate from the membrane, when it can be removed 
from the nose without difficulty. (Fig. 21.) 

Another case calling for variation from the usual 
procedure, and almost as common as the spur and 
groove, is a result of the breaking, or more correctly, 
the smashing of the septum, with both bone and carti- 
lage involved. As a result of this injury there has 
been a formation of fibrous tissue w\\\ ^^^ixorcv ^\. *^^ 
membranes on both sides oi t\\e sep\.wvc\. T<:^ ^^•j^^X'Csx 


these cases, open up the incision in the usual way. Use 
a curette to gain space. It will usually be found ad- 
visable to continue the use of the curette until the line 
of cleavage has been located. After this point has 
been reached the usual procedure applies, except that 
it may be necessary at times to use a knife in loosening 
the adhesion. 

We have already alluded to a type of deviation in 
which the deflection is almost at right angles to the 
perpendicular line, with a cul-de-sac formed by dislo- 
cation in a posterior position. The formation of 
fibrous tissue which has resulted completely separates 
the two severed portions of the septum and unites the 
muco-perichondrial surfaces. In such a case, make the 
usual incision and separate the membranes on both 
sides up as far as the cul-de-sac. Then, with the 
curette or forceps, remove all the cartilage, except the 
ridge above. (Fig. 23.) Working high in the nose, 
separate the membranes behind the cul-de-sac and on 
the concave side. They are usually not so adherent in 
this region. Then curette through on a line a short 
distance posterior to the sharp angle, removing the 
cartilage but leaving the ridge. After this stage is 
reached, the procedure becomes the usual one. It is 
to be noted that in this case there are two curettes 
through the cartilage, one anterior, the other posterior. 
When this has been done and the adherent membranes 
loosened, hook the cartilage at the high point and bring 
downward and forward with a sweeping motion to- 
ward the obstruction. (Fig. 24.) 

Inasmuch as it sometimes happens to the most care- 
ful operator that he punctures or tears the opposite 
membranes, it is well to know how to remedy them. 
The following procedure, devised by the writer, gives 
excellent results in a large number oi ease?^*. T>t\n^ ^. 
needle, preferably of the style oi Y?vtvkaw^x'?» oxtn^^ 

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Pig. 21 — Showing removal of spur with curette. 


Fig. 22— ShQ' 


suture needle, threaded with silkworm gut, well into 
the tissue anterior to the incision and low down near 
the floor of the nose. Then push the needle upwards 
and backwards so that it will cross the line of the 
incision as high as necessary in the nose. After the 
needle is in position, holding the gut with angular 
forceps, withdraw the needle. If the perforation is 
small, it is unnecessary to reach as high on the mem- 
brane. But if the perforation is large, then separate 
the mucous membrane as high as the bridge of the 
nose, cutting with a knife from the side on which the 
flap is being made, as illustrated in Figure 8. The 
membrane having been loosened enough to allow the 
flap to fall into position (see Fig. 25), the suture is 
drawn with a running loop (see Fig. 25) and after- 
wards tied with a surgical knot. On account of the 
free circulation of blood in the septum there is prac- 
tically no danger of a necrotic flap. Pack the nose 
lightly and not too far posterior, to avoid ear difficulty, 
using vaseline gauze. In twenty-four hours the gauze 
may be removed on the opposite side ; in forty-eight 
hours on the side on which the perforation has beai 
repaired. The suture is left in position several days, 
until it begins to cut itself out. 

It is in these special cases that the operator on the 
septum finds his greatest difficulties, just because they 
confront him with unexpected conditions. But pa- 
tience and skill and a cool head combine with the 
knowledge of the experience of others to simplify the 
problem. As these special cases give the greatest diffi- 
culty to the patient also and call most insistently for 
correction, the writer feels justified in the attempt to 
describe a procedure which calls more urgently for a 
skillful hand than for language, and which is, there- 
fore, hard to translate from action to words. 

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The cases described in this chapter have been 
chosen with the purpose of illustrating ways in which 
human behavior and idiosyncrasy in its many forms 
complicate the mechanics of surgical practice. Exam- 
ples are also given of the cases which violate the gen- 
eral rules of procedure, as in the case of children and 
young people. Cases of asthma which show a definite 
causation in structural defect, and the cure by resec- 
tion of ear troubles arising from nasal obstruction, 
are illustrated. 

It will be of interest to readers who have come in 
contact with individuals returned from the draft army 
to civilian life in an apparently normal state, but who 
have a history of what has mistakenly been called 
''shell-shock," that these persons often prove prac- 
tically inoperable under local anesthesia for the cor- 
rection of deviations. Several of these cases have 
come under the writer's direct observation. During 
the winter of 1921, a sturdily built young man, Amer- 
ican, a veteran of the World War who had never been 
wounded but who had been treated for mild shock, 
was presented for operation. Without warning, at the 
moment when the initial incision was to be made, he 
collapsed. Neither restoratives nor encouragement 
had effect, so that when the heart action was found to 
be . slightly involved, the case was abandoned. The 
more recent literature dealing with war neuroses has 
modified the former attitude toward these individuals 
whose self-control has been lessened by strain and 
shock. Hurst has said of these states : "Given a suffi- 
ciently powerful suggestion, there are probably no in- 
dividuals who would not develop (these) hysterical 

^ Croonian Lectures on the Psychology of the Special Senses 
and their Functional Disorders. Delivered before the Royal 
College of Physicians, in June, 1920, by Arthur F. Hurst, M. A., 
M. D., Oxon., R. F. C. P. London, 1920. 


It cannot be too frequently reiterated that the opera- 
tion for resection of the septum should not be j^er- 
formed on too young children. But, now and then, 
there are cases in which this rule must be broken, be- 
cause of the seriousness of the obstruction. Miss C, 
an American girl of fifteen years, brought to the office 
by her mother in 1915, was an exception. There was 
a history of a fall from a tree at the age of eight years, 
with a fracture of the nasal bones and septum which 
had resulted in an almost complete obstruction of the 
anterior nares. The mother told of the difficult 
breathing which had become associated with a chronic 
laryngitis, a tendency to a high-arched palate, and a 
marked lack of development of the nose. The patient 
complained of a whistling and ringing sound in the 
ears, the usual and irritating symptom of a chronic 
catarrh in the middle ear, also, at times, a purulent 
discharge. These conditions had combined with the 
disturbances of puberty to call for correction by re- 
moval of the lower part of the septum, and thus pre- 
vent the gradual involvement of the entire respiratory 

The patient's nervous temperament made it neces- 
sary to perform this operation under general anes- 
thetic, thus changing the position taken by surgeon and 
patient in the classic operation. After anesthetic, 
a large posterior plug was inserted in the pharynx, in 
order to prevent the blood from flowing in the throat. 
The usual incision was made. The incisor crest and 
the lower part of the deviated cartilage with part of 
the osseous septum were removed. It was found nec- 
essary to curette most of the cartilage removed, as it 
was very adherent. Not so much of the septum was 
removed, however, as would have been done in the 
case of an adult, but sufficient to give free ventilation. 


This operation was not a complete resection, the pur- 
pose being to remove only so much of the growing 
cartilage of the child as would afford a good breathing 
space. In the interval since this operation, the nose 
has developed, the breathing has become normal, and 
the ear trouble has disappeared. But it is only in such 
cases, where development is flagrantly retarded and 
where the sense organs are in danger of permanent 
impairment, that operation on growing children is ad- 

An extreme case, indicating an operation in boy- 
hood, was that of R., sixteen years old, whose septum 
had been fractured in a forceps delivery. The septum 
was pressing on the turbinate, and the turbinate was 
interfering with the drainage from the ethmoids, the 
frontal sinus and the antrum on the right side. 
The malformation early became associated with a 
polypus degeneration of the turbinate. The frontal 
sinus condition, protruding eye, and swollen face, 
showed the necessity for correction. In the opera- 
tion, performed under ether, most of the perpendicu- 
lar plate was removed together with the right middle 
turbinate and polypus. The ethmoidal cells, full of 
pus, were cleaned out by the Faulkner operation. This 
case was so bad that a nearly complete removal of the 
cells by the internal nasal route, with free drainage as 
the aim, was all that could be done, with no attempt to 
correct the external injury. The boy has made a com- 
plete recovery. 

Another case, marked by nervous complications 
which affect recovery was that of Mrs. D., a white 
woman of Irish extraction, forty-six years old, tall 
and thin, who showed on examination a marked ten- 
dency to hyperesthesia. Although the deviation from 
which she was suffering was plainly traumatic, with 


the associated gutter formation described in Chapter 
III and illustrated in Figure 5-c, she insisted that she 
could not remember the time when she had not suf- 
fered from interference in breathing. The right mid- 
dle turbinate was found, on examination, to be con- 
siderably enlarged, giving a partial cause for her com- 
plaint of fullness of the right nostril. Both nostrils 
were slightly atrophic, and a synechia was present on 
the right side, between the lower turbinate and the 
nasal septum. In spite of the nervous condition of 
the patient it was seen to be necessary to remove the 
middle turbinate along with the submucous resection. 
The removal of the turbinate makes the operation 
somewhat longer and more painful; but a discharge 
from under the turbinate, and the cloudiness of the 
ethmoids and antrum shown upon transillumination, 
indicated its necessity. In spite of the fact that some 
of the disturbances of which the patient complained 
were the result of the climacteric, it was believed that 
the suppurative disease of the accessory sinuses was 
responsible for at least part of the severe headaches 
from which she suffered. The operation would give 
drainage and thus relieve both the physical and nerv- 
ous condition. Under local anesthesia the septum was 
straightened and the turbinate removed for drainage. 
A well-developed ethmoidal cell was found in the right 
middle turbinate. A discharge which continued for 
some time after the operation was finally cured. The 
patient complained for some time of breathing first 
through one nostril, then the other, but treatment and 
suggestion that she pay less attention to her breathing 
finallv overcame this form of nervousness. This is a 
very usual history for disturbance of long standing 
and the various symptoms need give the patient and 
physician little concern. When the nose is given ven- 


tilation, nature will take care of the rest, if there is no 
necrotic tissue remaining and the patient will give his 
nose a chance. In all such cases there is a tendency 
to too frequent lavage with salines. This should not 
be indulged except when there is purulent discharge, 
and then under careful direction. It is to be remem- 
bered that the freeing of the air passages from ob- 
struction will of itself prove the most wholesome cor- 

The relief of asthma by resection is illustrated in 
the case of Mr. G., a German-American, age fifty, 
occupation, butcher. Mr. G. had sought relief in 1912 
from increasing asthmatic symptoms. At the time his 
trouble was diagnosed as the result of polypus 
growths, which were removed. The asthma was re- 
lieved for a time by this operation, but it gradually 
returned in an aggravated form, accompanied by con- 
stant harsh and labored breathing. This return had 
made Mr. G. distrustful of surgeons, but after seven 
years his condition was so bad that he was forced to 
seek relief. He then consulted the writer. Examina- 
tion showed that the heavy breathing was associated 
with a slight affection of the apexes of both lungs. 
Attention was also directed to a marked posterior de- 
viation of the nasal septum involving both bone and 
cartilage. (See Fig. S-c.) It was explained to Mr. 
G. that this deviation was in all probability the original 
cause of the difficulties from which he had been suf- 
fering; and that, although many adjacent structures 
had become so involved that he could not hope for 
immediate relief, still his only hope of ultimate re- 
covery lay in the correction of the deviation by sur- 
gery, with a removal of the ethnioids which had be- 
come involved in the degenerative process. The mem- 
ory of the previous experience had left the patient so 


skeptical that, although he was strongly advised to 
submit to the operation at once, it was postponed until 
November, 1920, almost a year from the time of diag- 
nosis, and until he was ill with an aggravated attack 
of asthma. In spite of his bad physical state, there 
were no unusual conditions. The polypus, middle 
turbinate and ethmoids were removed by the Faulkner 
method. Up to the present time (November, 1921) 
there has been no tendency to a return of the asthmatic 
condition. The patient, who had become emaciated 
and despondent, is gaining weight and is improving in 
spirits. There is little doubt that in this case the cor- 
rection at the eleventh hour saved the patient from a 
serious involvement of the whole respiratory tract as 
well as from a state of morbid depression resulting 
from the failure of the first operation to correct the 

A similar case to that of Mr. G. was that of Adolph 
G., German-American, age forty, a steel engraver by 
trade. Adolph came to the office as a private patient, 
giving a history of an asthmatic condition covering a 
period of twenty years. One of the persistent symp- 
toms was pain in the nostrils. Examination disclosed 
a high Z-deviation, very pronounced on the right side. 
The classic operation, described in Chapter IV, was 
performed on this patient in May, 1909. During the 
twelve years since, he has reported at the office at 
intervals for treatment for ordinary coryza, but states 
emphatically that there has never been a recurrence 
of the asthmatic difficulty of the twenty years previous. 

These two cases, among others, indicate strongly 
that there may be structural difficulties at the root of 
many cases of asthma, as also in the case of hay fever 
and "rose colds." Case histories of these difficulties 
which sooner or later involve the nervous system 


show a nasal phase, with sneezing attacks from 
minor causes developing into a conditioned reflex stage. 
Alterations in irritability reenforce certain normal 
impulses and cause them to overflow their customary 
channels. This condition may well be more marked 
in certain patients with inherited instability of the 
central nervous system. Prolonged after-care of such 
cases is desirable, with an effort at reeducation affect- 
ing the reflexes. Other cases indicate the correction 
of dietetic and sexual excesses to reenforce the struc- 
tural correction. The writer knows definitely of cases 
in which failure in the patient to correct the reflexes 
associated with a long-continued structural difficulty 
have positively countered the complete correction of 
what is usually the main cause of the trouble, namely, 
the closing of the nasal passages by injury. It is for 
this reason that in so many cases it is impossible to 
say whether it was the injury to the septum, or the 
nervous condition following the injury, which started 
the long series of after-effects in breathing, sneezing, 
and coughing idiosyncrasies. One thing remains true, 
however, that the clearing of the air passages by oper- 
ation, accompanied by correction of behavior, results 
in most cases in complete cures. 

Among the cases of serious ear trouble corrected 
l)y the resection of the nasal septum, is that of Patrol- 
man E. McE., Irish-American, forty-two years of age, 
of the New York City police force. This man, of 
stalwart build and otherwise of normal health, came 
to the office at intervals in 1908-9 with a history of 
successive and persistent colds which were beginning 
to affect his efficiency as an officer. These colds had 
affected his ears to such an extent that he suffered 
from severe headaches as a result of stoppage. The 
right ear was especially affected, as was the right side 


of the nose, through which he could not breathe. The 
ear trouble, which was accompanied by purulent con- 
dition which at times threatened serious complica- 
tions, was first attacked. Examination had revealed 
an almost complete obstruction of the right nasal 
cavity, resulting from traumatic deviation, but because 
of the patient's objection to operation, an attempt was 
made to remedy the ear condition by local treatment 
without an attack on the cause of the trouble in the 
obstructed nose. After five years of treatment, with 
constant recurrences of trouble with the right ear, a 
refusal to treat the local trouble brought Patrolman 
McE. to an operation. This operation, performed 
seven years ago, resulted in complete recovery. In 
his own words, taken from a letter written December 
15, 1920, the time of the year when he would be most 
liable to recurrence, he says: "After I was operated 
on by you, I could breathe freely through both nostrils,, 
and am enjoying good health to the present time. I 
have gained in weight, and have not been suffering 
from the succession of colds as heretofore mentioned. 
. . . My nose appears straight, and has not fallen 
in any. Although I have received several punches, it 
has not broken under the strain. . . An X-ray exam- 
ination indicates that the septum is straight." 

The case histories here given have been among the 
number which are convincing as showing the necessity 
of a developing and flexible technic to meet the spe- 
cial conditions which are constantly confronting the 
surgeon. They show the nasal septum as a disturbing 
factor, and fully justify dealing with it by operative 
procedure, when other means fail. 


One of the most unfortunate results that can come 
from faulty technic in the operation for resection of 
die septum is the falling in of the septum, which 
results in the condition called, from its appearance, 
the saddle-back nose. 

There are several causes which may combine to 
produce this unfortunate complication, some of which 
are important enough for discussion. 

Eirst : If the mucous membrane is separated at a 
point along the ridge so high as to cause a cleavage 
from the lateral cartilages and the triangular cartilage 
as well, there may result a falling in of the dividing 
wall. This will account for a very limited number of 
these cases, which are evidently preventable. It can 
be guarded against by cautious procedure at the point 
of articulation between the triangular cartilage and the 
perpendicular plate of the ethmoid. When this point 
in the operation is reached, the separation should be 
accomplished by the removal of the cartilage with a 
sharp cutting instrument so as to have no pulling or 
separation at that point. 

Second : Hemorrhage between the flaps, during the 
period of convalescence, may cause a falling of the 
septum. These hemorrhages are generally low down 
along the floor of the septum, but the hemorrhage may 
be so profuse as to cause a separation of the lateral 
cartilages, and when this occurs it is generally in the 


first few days after the operation. Bad results may be 
prevented by a close watch over the patient. To treat 
properly, make a perpendicular incision with a knife. 
Insert cutting forceps, such as those of the Jansen- 
Middleton type, parallel with the floor of the nose for 
about two-thirds of the length of the blade. Remove 
the membrane and clean out the clots and debris. As a 
rule there will be little further trouble. The perpendicu- 
lar incision for drainage purposes is of little moment, 
because the cut surfaces will unite in a short time. 

Third : A purulent secretion between the flaps as a 
result of abscess is another possible cause of a falling 
septum. This appears at a later date than hemorrhage. 
Generally the first symptom is a swelling on both sides 
of the remaining ridge nearer the junction of the carti- 
lage and the perpendicular plate. If not corrected, pus 
will sometimes nearly fill the space between the flaps. 
We have already said that, in a number of operations, 
we find ourselves compelled to leave a part of the de- 
viation high up along the ridge. When we examine 
one of these cases we find on the side where the carti- 
lage has been left an apparent bulging. On the other 
side there will be no swelling under normal conditions. 
But in the case of abscess, when we examine the nose 
with a speculum, we will find an almost equal bulge 
in each nostril on both sides of the septal wall. Treat- 
ment consists of cocainizing the septum at the bulge 
and making a perpendicular incision through the 
swelling. If pus is present it can be reached with 
little difficulty. The first incision is for diagnostic 
purposes only. For drainage, proceed with Jansen- 
Middleton forceps as in the case of hemorrhage. If 
the nose is kept free from clots there will be few 
grave results in the case of either hemorrhage or ab- 


scess. It is well, however, to watch these patients 
carefully for a number of days. 

Fourth : An atrophy of the remaining cartilaginous 
tissue will sometimes cause the support of the wall to 
be absorbed. Just what causes this atrophy and ab- 
sorption is sometimes difficult to tell. In some cases a 
syphilitic condition is found. Again, pressure on the 
septum, sometimes unexpected, at other times through 
wilfulness of the patient, will result in a cave-in. A 
young woman, on one occasion, came to the office on 
the fourth day after an operation. The nose was 
swollen and giving her considerable pain. In an irri- 
tated fashion, she placed her index finger on her nose 
and pressing it flat asked if the nose were going to 
stay in that position. When earnestly requested not 
to do so dangerous a thing and warned of the possible 
result, she repeated the procedure. On examination, 
it was found that she had pulled away the portion of 
the triangular cartilage which articulates with the per- 
pendicular plate of the ethmoid. Today, this young 
woman has a marked deformity as a result of her 

Although the causes enumerated above might in- 
dicate that this result of the operation on the septum 
occurs frequently enough to make the operation dan- 
gerous to good looks, as a matter of fact, the accident 
of the cave-in is rare. Constitutional difficulty is the 
only real reason for its ever occurring. Care in the 
operation, care and patience on the part of the patient, 
and watchfulness of the healing process on the part 
of the operator, will prevent these cases. Their fre- 
quency is exaggerated because the conspicuousness of 
the nose makes every such mishap visible to every pas- 
ser-by. It need never cause a patient to hesitate to 
entrust himself to a careful operator. 


A review of the pages of this book is, for its author, 
a retracing of the steps that brought him through the 
years to the place where he is ready to put in form for 
others the fruits of his experience. First came the 
study of the normal nose, its structure of bone and 
cartilage, its circulatory and nervous system, and its 
functioning, so important in the life of the individual. 
When we think of the results of malformation of the 
nose in its disturbance of two of the special senses, 
smelling and tasting, with its less direct, but none the 
less, serious disturbance of sight and hearing, and the 
resulting affection of the respiratory tract, we realize 
the far-reaching importance of careful study of these 
disturbing conditions. As the victims of septal devia- 
tion have come in steady procession through office and 
clinic through the years, gradually the general class- 
ification of these deviations, given in Chapter III, has 
taken form. Such a classification does not mean 
necessarily that any one case can be said to be a 
"normal" S- or Z-deviation. It rather means that as 
cases of this or that sort are superimposed in memory, 
they become a "composite picture" looking like one or 
the other type. 

The type or picture once in mind, next comes the 
working out of an operation that will meet the condi- 
tions of such deviation as nearly as can be. Such an 
operation, always looked upon by the most skillful of 


Sf:e Table of Contents 




To avoid fine, this book should be relurnedjaJ 


oui 10 laid 




R345 Dunning, W.]'. 

D92 The subraufloue resec- 

1921 tlon of the nasal sep-